Billing and first fill program

Pharmacy providers are required to submit bills for outpatient medications at the point-of-service in all claims

Existing claims

Pharmacy providers are required to submit bills for outpatient medications at the point-of-service in all claims, including situations prior to a BWC claim number being assigned. In order to submit a bill at the point-of-service, the pharmacist must transmit at least two of the following three items, along with the other billing information, to the pharmacy benefit manager (PBM):

BWC claim number;

Social Security number; and/or

Date of injury.

The PBM verifies the information, processes the bill and sends the pharmacist an appropriate message based on the claim’s status, allowed conditions and formulary coverage and restrictions. The PBM pays pharmacy provider bills according to BWC’s fee schedule.

Outpatient medications administered at a skilled nursing facility are to be obtained from a licensed pharmacy provider that electronically submits the bill(s) to the PBM for payment, and delivers the medication to the facility for administration.

First Fill Program

BWC established a program to provide reimbursement for the first fill of prescription drugs for medical conditions identified in a pending workers’ compensation claim. The program is limited to the first fill of prescription drugs that occur prior to the date BWC issues an initial claim determination order.

Prescription reimbursement is limited to the following:

A period of 10 days or less at the most commonly prescribed dosing schedule, and no refills will be approved;

One drug per therapeutic drug class listed in the appendix to the rule;

Extemporaneous compounded prescriptions are not eligible for reimbursement under the first fill program and;

Prescription drugs listed in the appendix to the rule along with the maximum quantity of each. Prescription drugs not listed in the appendix are not eligible for reimbursement unless prior authorization was approved by BWC.

The prescribing physician or their agent must write 'work-related injury' on and sign the prescription in order for the prescription to be eligible for the first fill program. Pharmacists and pharmacy interns are permitted to write the phrase and sign telephone prescriptions. The pharmacy provider is guaranteed payment for reimbursed prescription drugs so long as the first fill program requirements are followed regardless of final claim acceptance or denial.

First fill prescriptions are reimbursed in the same manner as other prescriptions. Pharmacy providers should follow the steps outlined above in the existing claims section for guidelines. Custom messaging will direct the pharmacy provider to resubmit the prescription after consulting the first fill medication list to ensure coverage.

Generic drug requirement

BWC does not reimburse for brand name drugs when a generic equivalent is widely available. This rule applies to all claims, regardless of date of injury. If a brand name drug is dispensed, the injured worker pays the difference in price between the generic price and the brand name drug requested.

Injured worker outpatient medication reimbursement

Injured workers can request payment for prescribed outpatient medication only. Since pharmacy providers are expected to submit bills directly to BWC’s pharmacy benefits manager (PBM) electronically, the use of the C-17 reimbursement request form should be rare or for special circumstances.

MCOs determine reimbursement eligibility for the following services that may be obtained in a pharmacy: Contact the MCO for specific requirements for the use of the Service Invoice (C-19) or HCFA 1500 — MCOs determine reimbursement eligibility for the following services that may be obtained in a pharmacy: Contact the MCO for specific requirements for using the C-19 and HCFA 1500.

MAC pricing policy

The Ohio Bureau of Workers’ Compensation (BWC) utilizes a Maximum Allowable Cost (MAC) pricing program for retail pharmacy reimbursement. The MAC program aligns the incentives for the pharmacy, injured worker and the BWC program.

BWC is committed to ensuring that MAC pricing allows for retail pharmacy profitability while ensuring the cost effective use of program funds. For all generic products, the objective is for the pharmacy to make equivalent or greater gross profit percentage per prescription as compared to the equivalent brand product.

The program’s funds will be used to continue providing quality prescription coverage to Ohio’s injured workers’. The MAC prices will maintain reasonable profitability incentives to dispense generic products over brand products.

Drug shortages and pricing

Drug shortage information is verified through the FDA website. In addition, if you feel a product is in short supply or unavailable; please fax the information to BWC using the MAC Price Inquiry form.

Use the MAC Price Inquiry form to provide feedback for both MAC pricing and multiple source generic product availability. BWC will research concerns submitted via the MAC Price Inquiry form within 24 hours of receipt.

Products with supply issues, where no generics are available, will be removed from the MAC list within 24 hours of discovery and non-MAC pricing will apply. Products with supply issues, where other generics are available, will have pricing modified within 24 hours of discovery. Once supply issues have been resolved on these products, the MAC price will be reestablished.

Exception process to update MAC list

The MAC list will be reviewed with ongoing adjustments based upon market changes in pricing and product availability. BWC and the PBM will work jointly to review items where profitability is questioned. For further questions concerning the MAC list, please contact BWC at 1-877-543-6446.